Safety issue

Safety issue description

Although National Jet Systems contained procedures for recognition and management of pilot incapacitation, the associated training did not include the identification and response to subtle physical or cognitive incapacitation.
Issue number AO-2023-026-SI-02
Issue owner National Jet Systems
Transport function Aviation: Air transport
Issue status Closed – Adequately addressed
Date issue released 16/04/2024
Issue status justification

The ATSB acknowledges National Jet Systems’ safety actions of targeted training and procedures to address the risks of subtle physical or cognitive incapacitation in flight crews. These actions are considered to address the safety issue.

Safety action

Action type Proactive action
Action number AO-2023-026-PSA-03
Organisation National Jet Systems
Action date 02/03/2024
Action description

On 2 March 2024, National Jet Systems advised the ATSB of the following safety actions taken as a result of this occurrence:

  • The flight crew recurrent simulator training syllabus had been updated to include in‑seat instruction specific to pilot incapacitation, followed by a practical exercise donning oxygen masks and conducting an approach, landing, and taxiing to the gate while using oxygen.
  • A review of smoke/fumes checklist and simulator training was undertaken.
  • Learnings from this occurrence have been incorporated into the newly‑introduced company A220 aircraft smoke/fumes, hypoxia, and incapacitation procedures.
  • A review of hypoxia training material to include specific reference to histotoxic hypoxia was undertaken, with draft content awaiting input from the Qantas chief medical officer.

Aircrew emergency procedures documentation and training pertaining to the recognition and management of crew incapacitation have been updated to include subtle and cognitive incapacitation.